Updated: 6/27/2021

Lower Extremity Spine & Neuro Exam

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
2
0
0
0%
0%
Evidence
5
0
0
0%
0%
Videos / Pods
2
Topic
Images
https://upload.orthobullets.com/topic/2002/images/lumbar_nerve_roots_3.jpg
https://upload.orthobullets.com/topic/2002/images/LE dermatomes_moved.jpg
  • Overview
    • Note: The table below is a simplification as muscles are often innervated by multiple nerve root
      • for example, ankle dorsiflexion usually has a contribution from both L4 and L5
    • Lower Extremity Spine and Neuro Exam
      Nerve root
      Primary Motion
      Primary muscles 
      Sensory
      Reflex
      L1
      Iliac crest and groin
      Cremasteric reflex (L1 and L2)
      L2
      Hip flexion and adduction
      Iliopsoas (lumbar plexus, femoral n.)
      Hip adductors (obturator n.)
      Anterior and inner thigh
      Cremasteric reflex (L1 and L2)
      L3
      Knee extension (also L4)
      Quadriceps (femoral n.)
      Anterior thigh, medial thigh and medial knee
      -
      L4
      Ankle dorsiflexion (also L5)
      Tibialis anterior (deep peroneal n.)
      Lateral thigh, anterior knee, and medial leg
      Patellar 
      L5
      Foot inversion
      Toe dorsiflexion
      Hip Extension
      Hip abduction
      Tibialis posterior (tibial n.)
      EHL (DPN), EDL (DPN)
      Hamstrings (tibial) & gluteus max (inf. gluteal n.)
      Gluteus medius (sup. gluteal n.) 
      Lateral leg & dorsal foot
      -
      S1
      Foot plantar flexion
      Foot eversion
      Gastroc-soleus (tibial n.)
      Peroneals (SPN)
      Posterior leg
      Achilles
      S2
      Toe plantarflexion
      FHL (tibial n.), FDL (tibial) 
      Plantar foot
      -
      S3 & S4
      Bowel & bladder function
      Bladder
      Perianal
      -
  • History & Symptoms
    • Characteristic symptoms
      Systemic symptoms (weight loss)
      Tumor, infection
      Evaluation of localized axial pain
      Tumor, infection
      Mechanical pain
      Instability, discogenic pain
      Radicular pain
      HNP
      Night pain
      Tumor
      Referred pain
      Peptic ulcer disease, cholecystiits, nephrolithiasis, PID, pancreatitis
      Concomitant pain
      Hip & shoulder
      Psychogenic
      Secondary gain
    • Inspection
      • skin
        • looking for prior scars, cafe au lait spots, hairy patches in the lower lubmar spine
  • Motor Exam
    • Muscle Grading System (ASIA)
      0
      Total paralysis
      1
      Palpable or visible contraction
      2
      Active movement, full range of motion, gravity eliminated
      3
      Active movement, full range of motion, against gravity
      4
      Active movement, full range of motion, against gravity and provides some resistance
      5
      Active movement, full range of motion, against gravity and provides normal resistance
      NT
      Patient unable to reliably exert effort or muscle unavailable for testing due to factors such as immobilization, pain on effort, or contracture.
  • Sensory Exam
    • Sensory Grading System (ASIA)
      0
      Absent
      1
      Impaired
      2
      Normal
      NT
      Not Testable
  • Specific Tests
    • Special tests
      • straight leg raise
        • compression of lower lumbar nerve roots (L4-S1)
        • important to distinguish from hamstring tightness
        • considered positive if symptoms produced with leg raised to 40°
      • crossed straight leg raise
        • performing straight leg raise in uninvolved leg produces symptoms in involved leg
      • Babinski's test
        • positive findings suggests upper motor neuron lesion
      • ankle clonus test
        • associated with upper motor neuron lesion
      • bulbocavernous reflex
        • tests for the presence of spinal shock
        • positive reflex with anal sphincter contraction with squeezing of glans penis or clitorus
          • can alternatively tug on foley catheter to stimulate reflex
    • Lumbosacral plexus illustration
    • Sensory illustration
  • Clinical Findings
    • Clinical Findings
      Symptoms
      Neurologic etiology
      Causes
      Paresthesias alone medial aspect of knee
      Irritation of saphenous division of femoral nerve
      • Psoas abscess
      • Saphenous n. compression (surfing)
      A Trendelenburg gait
      Injury to L5 nerve root
      Paracentral L4/5 HNP
      Numbness along lateral thigh
      Meralgia paresthetica (lateral femoral cutaneous nerve palsy)
      Compression of LFCN (patient positioning)
      Foot drop
      Common peroneal nerve palsy or sciatic nerve compression
      • Lateral knee compression
      • Hip dislocation
      Quadriceps weakness
      Femoral nerve palsy
      • Hyperflexed Pavlik harness
      • L3 and L4 nerve root compression
  • Waddel Signs
    • Waddell identified 5 exam findings that correlated with non-organic low back pain. The tests include
    • Waddell Signs
      Finding
      Description
      1. Tenderness
      a. Superficial - pain with light touch to skin
      b. Deep - nonanatomic widespread deep pain
      2. Simulation
      a. Pain with light axial compression on skull
      b. Pain with light twisting of pelvis
      3. Distraction
      No pain with distracted SLR
      4. Regional
      a. Nonanatomic or inconsistent motor findings during entire exam
      b. Nonanatomic or inconsistent sensory findings during entire exam
      5.Overreaction
      Overreaction noted at any time during exam

Please rate this review topic.

You have never rated this topic.

Thank you. You can rate this topic again in 12 months.

Flashcards (0)
Cards
1 of 0
Questions (2)

(OBQ13.22) A Trendelenburg gait would most likely be caused by which of the following lumbar conditions.

QID: 4657
1

L3/4 far lateral disc herniation

23%

(1286/5615)

2

L3/4 central disc herniation with impingement on the bilateral descending nerve roots

3%

(182/5615)

3

L4/5 far lateral disc herniation

15%

(819/5615)

4

L5/S1 far lateral disc herniation

53%

(3000/5615)

5

L5/S1 paracentral disc herniation

5%

(305/5615)

L 4 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidence (5)
VIDEOS & PODCASTS (2)
EXPERT COMMENTS (21)
Private Note